Pocket occur with the destruction of the supporting periodontal tissues

1. PERIODONTAL POCKET
PRESENTED BY –
SRISHTI SRIVASTAVA
BDS

2. • When the sulcular depth is more then
three millimeters, will allow food debris
and microbes to accumulate. This poses a
danger to the periodontal ligament (PDL)
fibers that attach the gingiva to the tooth.
If accumulated microbes remain
undisturbed in a sulcus for an extended
period of time, they will penetrate and
ultimately destroy the delicate soft tissue
and periodontal attachment fibers. If left
untreated, this process may lead to a
deepening of the sulcus.
Introduction

3. • Pocket can be defined as
pathologically deepened of the
gingival sulcus. (CARRANZA)
• Pocket occur with the destruction of
the supporting periodontal tissues.
Definition

4. • The periodental pockets are caused
by micro-organism and their
products,which produce pathologic
changes that lead to the deepening
of the gingival sulcus.
Etiology

5. Classification -

6. • GINGIVAL POCKET (PSEUDO
POCKET):
• This type of pocket is formed by gingival
enlargement without destruction of the
underlying periodontal tissues. The sulcus
is deepened because of the increased bulk
of the gingiva

7. • Periodontal pocket:
• This type of pocket occurs with
destruction of the supporting
periodontal tissues. Progressive
pocket deepening leads to destruction
of the supporting periodontal tissues
and loosening and exfoliation of the
teeth.

8. • Suprabony (supracrestal or
supraalveolar), in which the base of
the pocket is coronal to the underlying
alveolar bone.
• Intrabony (infrabony, subcrestal or
intraalveolar), in which the base of the
pocket is apical to the level of the
adjacent alveolar bone.

9. Different types of
periodontal pockets
A, Gingival pocket-There is no destruction of the
supporting periodontal tissues
B, Suprabony pocket-The base of the pocket is coronal to the
level of the underlying bone.
C, Intrabony pocket. The base of the pocket is apical to the level of the
adjacent bone. Bone loss is vertical.

10. • SIMPLE POCKET-involving one tooth
surface
• COMPOUND POCKET- involving two or
more tooth surface
• COMPLEX POCKET-base of the pocket is
not in direct communication with the
gingival margin, also c/a spiral pocket.

11. A-Simple pocket.
B-Compound pocket.
C-Complex pocket

12. Signs
• enlarged,bluish red marginal gingiva with a
rolled edge seprated from the tooth surface.
• Bluish red vertical zone extending from the
gingival margin to the alveolar mucosa.
• A break in the faciolingual continuity of the
interdental gingiva.
• Shiny,discolored and puffy gingiva
associated with exposed root surface.
clinical features

13. • Gingival bleeding , purulent ` from
the gingival margin.
• Mobility , extrusion and migration of
teeth.
• The development of diastema.

14. • Localised pain or a sensation of
pressure in the gingiva after
eating,which gradually dimnishes.
• A foul taste in localized areas
• Radiating pain “deep in the bone”.
• Feeling of itching in the gums
• The urge to dig a pointed instrument
into the gums and relief is obtained
from the resultant bleeding.
• Sensitivity to heat and cold.
symptoms

15. The gram-positive bacteria lays
down on the on the supragingival
tooth surface and extentd in to the
gingival sulcus.
As a result of inflammation,the
following changes are seen in the
junctional epithelium-
PATHOGENESIS

16. changes in junctional epithelium
prolifeartes along the root surface
(finger like projections)
coronal portion detaches apical portion of
from the root junctional epithelium migrates
due to bacterial enzymes and physical replaced by pocket epithelium
forces exerted by them
First event

17. • Colonization of Gram-positive
bacteria supragingivally and its
extension into the gingival sulcus
and conversion of Gram-positive
aerobes to Gram-negative
anaerobs.

18. aggressive growth and action of Gram-
negative bacteria
Emigration of neutrophils in large
numbers
Disruption of epithelial barrier
causing open communication
Second event

19. loss of chemotactic gradient
tissue destruction due to products
released by neutrophils as well as
bacteria
resorption of alveolar bone
periodontal pocket is established

22. • Once the pocket is formed , the
following microscopic features are
present-
Changes in the soft tissue wall:
 the blood vessels are dilated.
 The connective tissue is edematous and
densely infiltrated with plasma cells ,
lymphocytes.
HISTOPATHOLOGY

23. • Filaments , rods , cocoid organisms
with predominent gram (-) cell walls
have been found in intercellular spaces
of the epithelium.
• Bacteria may invade the intercellular
space under epithelial cells but they
are also found between deeper
epithelial cells and accumulating on
the basement lamina.
BACTERIAL INVASION

24. • The inflammatory response triggered
by bacterial plaque unleashes a
complex cascade of events , aimed at
destroying and removing bacteria ,
necrotic cells .
• The host cells such as neutrophiles ,
macrophages , fibroblasts , epithelial
cells and others , produce proteinases ,
cytokines and prostaglandins that can
damage or destroy the tissue .
MECHANISM OF TISSUE
DISTRUCTION-

25. • Under scanning electron microscope the
following areas have been noted:
1.areas of bacterial accumulation- which
appears as depression on the epithelial
surface with abundant debris and bacterial
clumps penetrating into the enlarged
intercellular spaces.
2.areas of emergence of leukocytes –
leukocytes appear in pocket wall through
holes located in the intracellular spaces .
3. Area of leukocytes – bacteria interaction
numerous leukocytes are present and
covered with bacteria in an apparent process
of phagocytosis .
MICROTOPOGRAPHY OF THE GINGIVAL
WALL OF THE POCKET

26. 4. Area of intense epithelial
desquamation -consist of semiattached
and folded epithelial squames .
5.area of ulceration with exposed
connective tissue
6.area of hemorrhage with numerous
erythrocytes.

27. • IT is characterized by interplay of destructive
and constructive tissue changes .
- The destructive changes are characterized by
fluid and cellular inflammatory exudates and
by the associated changes initiated by the
plaque bacteria .
- The constructive changes consist of the
formation of blood vessels in an effort to
repair the tissue damage caused by
inflammation .
• The balance between the destructive and
constructive changes determines the clinical
feature such as colour , consistency , and
surface texture .
PERIODOTAL POCKET AS HEALING
LESION

28. • It consists of –
debris - containing micro-organisms
and their products (enzyme , endotoxin
, and other metabolic products).
dental plaque
Gingival fluid
food remnants
salivary mucin
desqumated epithelial cell and
leucocytes
POCKET CONTENTS

29. • If the purulent exudate is present , it
consist of-
living , degenerated and necrotic
leukocytes , living and dead bacteria ,
serum and a scanty amount of fibrin .
pus formation is common feature in
periodontal disease but it only
secondary sign .

30. • 1- STRUCTURAL CHANGES –
A- presence of pathologic granules
B- areas of increase mineralization
C- areas of demineralization / root caries
• 2- CHEMICAL CHANGES –
the mineral content of exposed cementum
increased .
Mineral increased in root surface – calcium ,
magnesium , phosphate , floride and others .
• 3- CYTOTOXIC CHANGES – bacterial
penetration into cementum can be found as
deep as cementodentinal junction .
in addition , bacterial products such as
endotoxins have also been detected .
CHANGES IN ROOT SURFACE WALL

31. • 1-cementum covered by calculus.
• 2-attached plaque.
• 3-the zone of unattached plaque.
• 4-the zone where the junctional
epithelium is attached to the tooth.
• 5-the zone of semi destroyed C.T.
fibers.
Surface morphology of the tooth wall of the
periodontal pockets

32. ZONES IN THE BASE OF PERIODONTAL POCKET

33. Periodontal probes are used to locate,
measure, and mark pockets, as well
as determine their course on
individual tooth surfaces.
DIAGNOSIS

34. • Periodontal probes may be divided
into:
First generation probes are
conventional,
and hand held probes, e.g.
conventional periodontal probes.
Second generation probes are
pressure –sensitive probes. It has been
shown that, with forces up to 30gms
the probe tip remains within
junctional epithelium and forces up to
50gms are necessary to diagnose
osseous defects. This probe did solve
many problems of the conventional
probes, but lacked tactile sensitivity.

35.  Third generation probes are computerized
probes. Gibbs et al designed Florida probe.
E.g.-Foster Miller Probe, Toronto
Automated Probes, which can detect the
cemento-enamel junction.
 Fourth generation probes are the three
dimensional probes in which sequential
probe positions are measured.
 Fifth generation probes are
ultrasonographic probes which provides
painless probing to the patient. The
guidance path is predetermined in these
probes.

36. There are three types of periodontal
probes. They are:
1. Calibrated periodontal probes
2. Naber’s furcation probe
3. Computer assisted probes
TYPES OF PERIODONTAL PROBES

37. • There are two different pocket depths:
- The biologic depth is the distance
between the gingival margin and the
base of the pocket (coronal end of
junctional epithelium). This can be
measured only by histological sections.
- The probing depth is the distance to
which the probe penetrates into the
pocket.
POCKET PROBING

39. • The depth of penetration of the
probe in the connective tissue
apical to the junctional epithelium
in a periodontal pocket is about
0.3mm.
• The probing forces of 0.75N have
been found to be well tolerated
and accurate.

40. • The probe should be inserted parallel to the
vertical axis of the tooth and “walked”
circumferentially around each tooth to detect
the areas of deepest penetration.
• To detect an interdental crater the probe
should be placed obliquely from both the
facial and the lingual surface to explore the
deepest point of the pocket located beneath
the contact point.
• To detect furcation involvement in multi-
rooted teeth, use of specially designed
Naber’s probe allows an easier and more
accurate exploration of the horizontal
component of furcation lesion.
PROBING TECHNIQUE

42. • Probing of pockets is done at various
times for diagnosis and for monitoring
the course of treatment and
maintenance.
• Initial probing: Done to determine
whether the tooth can be saved or
should be extracted.
• Second probing: Done to establish
accurately the level of attachment and
degree of involvement of roots and
furcations.
When to probe

43. TREATMENT